Head Injuryinvestigation

CT scan in head injury

Scans must extend from the posterior fossa to the vertex, otherwise haematomas in these sites will be missed.

Midline shift with compression of ipsilateral ventricle

EXTRADURAL haematoma -area of increased density, convex inwards. Spread limited by dural adhesion to skull

SUBDURAL haematoma - area of increased density spreading around surface of cerebral hemisphere. Subdural haematomas become isodense with brain 10-20 days following injury and hypodense thereafter.

INTRACEREBRAL haematoma - 'BURST LOBE' (± subdural haematoma) - appears as an irregular area of increased density (blood clot) surrounded by area of low density (oedematous brain).

Midline shift with compression of ipsilateral ventricle

The contralateral ventricle often dilates due to obstruction at the foramen of Munro

The contralateral ventricle often dilates due to obstruction at the foramen of Munro overlying subdural haematoma

'Burst' temporal lobe

'Burst' temporal lobe

Chiasmatic cistern

Whether a haematoma is present or not, look at the basal cisterns.

normal Obliteration of one or both cisterns indicates raised intracranial pressure with brain shift from an expanding mass or hemispheric swelling

With diffuse shearing injuries, small haematomas may be seen on CT scan scattered throughout the white matter, particularly in the corpus callosum or in the superior cerebellar peduncle.

If hydrocephalus is present on the upper scan cuts, look carefully for a haematoma (extradural, subdural or intracerebral) in the posterior fossa, compressing and obstructing the 4th ventricle.

In the absence of CT scanning, ANGIOGRAPHY shows displacement of vessels and gives a useful guide to the haematoma site. Failing this, bilateral burr holes are placed in frontal, temporal and parietal sites; even in experienced hands, however, this exploratory approach will miss 30% of intracranial haematomas.

Further investigation may be required to exclude other coincidental or contributory causes of the head injury, e.g. drugs, alcohol, postictal state, encephalitis (Cause of coma, 224 see page 82).

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